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The Effects of on Cognition in Long-Term Care

Peter R. Johnson, Ph.D., CCC-SLP1

ABSTRACT

This article emphasizes the need to consider the role of when providing speech-language pathology services to a person with cognitive decline. This is particularly true when working with older adults. Many older adults take multiple medications that may have a direct effect on cognitive ability and as a result, on the success of rehabilitation efforts.

KEYWORDS: , neurotransmitters,

Learning Outcomes: As a result of this activity, the reader will be able to (1) identify the relationship between cognitive abilities and polypharmacy; (2) describe the relationship between the speech-language pathologist and physician; (3) explain the importance of a correct diagnosis and accurate staging when examining the cognitive function; (4) discuss the importance of understanding adverse reactions and side effects; (5) identify the role of classes of medication such as benzodiazepines to sedation.

The word cognition comes from Latin and care settings.1 Cognitive skills are the underly- means “to know.” Cognition is commonly ing skills and mental capacities needed to thought to include memory, attention, learning, process and learn information, read and re- problem solving, decision making, reasoning, member, solve problems, and think. Cognitive and language. Several of these cognitive pro- skills develop and change over time. cesses may be impaired in individuals who are in This article will discuss the effect of long-term care. Therefore, cognitive rehabili- medications on cognition and subsequently tation may play an important role in isolating on cognitive therapy. The importance of and identifying that can either improve or having the correct diagnosis and staging level

disrupt cognitive abilities. In most instances, will be emphasized. The article will also This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. however, medications are more likely to inter- discuss the clinician’s role in identifying fere with, rather than improve, cognition. This medications that may affect cognitive func- is particularly true for the elderly in long-term tioning. Finally, general classes of

1Select Medical Rehabilitation Services, Clearwater, Speech Pathologists in Long-Term Care; Guest Editor, Florida. Jennifer A. Brush, M.A., CCC-SLP Address for correspondence: Peter R. Johnson, Ph.D., Semin Speech Lang 2013;34:18–28. Copyright # 2013 CCC-SLP, Select Medical Rehabilitation Services, 4025 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, Tampa Rd., suite 1106, Oldsmar, FL 34677 (e-mail: New York, NY 10001, USA. Tel: +1(212) 584-4662. [email protected]). DOI: http://dx.doi.org/10.1055/s-0033-1337391. ISSN 0734-0478. 18 THE EFFECTS OF MEDICATION ON COGNITION IN LONG-TERM CARE/JOHNSON 19 medications will also be discussed in relation A person with vascular , on the to their effect on cognition. other hand, usually presents with an abrupt The first thing to consider when examining onset, somatic complaints, and difficulties in the cognitive patterns of older adults is their all aspects of sensory memory. Vascular demen- diagnosis. Frequently, individuals living in long- tia differs from other vascular disorders such as term care settings manifest some form of de- stroke in that, although the onset may appear to mentia. Dementia describes a group of brain be abrupt, it is likely to be the end result of disorders that cause loss of memory and other repeated, often unrecognized small strokes. The cognitive abilities. It is not a disease itself, but a person with vascular dementia has difficulty group of symptoms that characterize several with semantic memory, whereas the person diseases and conditions. Each type of dementia with AD has more difficulty with episodic has particular cognitive patterns that can then be memory.2 In contrast, a person with Hunting- influenced by medications. As such, accurate ton’s disease (HD) will experience deficits in and early diagnosis of the dementia type is procedural memory, which is considered a important for informing its management. spared ability until late in the time course of Each dementia type has distinctive patterns of AD. HD is a neurodegenerative disorder re- behavioral difficulties, memory loss, and other sulting in motor, cognitive, and psychiatric cognitive strengths and weaknesses unique to deficits. Differences such as these should be that diagnosis.2 Impairments in cognition are considered when evaluating the effects of med- usually classified as reversible or irreversible. ication on cognition.2 Reversible dementia results from a medicine’s Staging systems provide useful frames of side effects, as well as from , delirium, reference for understanding how a type of malnutrition and dehydration, depression, and dementia may progress, which is helpful for hypoglycemia. In addition, the cognitive im- developing treatment plans. However, all stages pairment may range from mild impairment are artificial benchmarks in a continuous pro- including age-associated mental decline to se- cess that can vary from one person to another. vere cognitive disabilities such as those seen in Not everyone will experience each symptom, people with frontotemporal dementia or with and symptoms may occur at different times in Alzheimer’s disease (AD), the most common different individuals. One common tool used by type of dementia in the United States.3 health care professionals is the Global Deterio- People with AD suffer primarily from ration Scale (also called the Reisberg Scale), impaired episodic memory; impaired orienta- which measures the progression of AD.6 This tion; reduced attention to task; reduced limits of scale divides AD into seven stages of ability. A concentration, planning, and judgment; per- score of 1 represents average cognition, a score sonality changes; and later, speech and walking of 4 represents moderate cognitive decline such disorders. Episodic memory decline is frequent- as difficulty with complex tasks, and a score of 7 ly accompanied with visual-spatial-temporal represents severe dementia. Certainly, individ- orientation difficulties. Anomia, sensory mem- uals with significant impairment or those in a ory, and working memory are also involved. more advanced stage will have more difficulty Generally, the higher-level mental functions compensating for changes in cognition caused This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. are affected first. Disorientation to time and by medications. It is thus essential for clinicians space may occur in the later stages.4 to be able accurately determine the patient’s Another form of dementia, Parkinson’s diagnosis and stage of dementia before trying to disease (PD), generally manifests a slowing of determine if the person’s cognitive levels have thethoughtprocessesaswellasdifficulty been affected by medications. Staging is also concentrating that leads to confusion. In important as the individual probably will re- addition, the person with PD may have diffi- spond differentially to therapy. This will affect culty with sensory memory, notably speed of the appropriateness of many neurobehavioral processing and subsequent difficulty with rehabilitation strategies. For example, the per- working memory, executive function, and son in stage three (early confusional) should metacognition.5 actively attend to notes placed in front of him 20 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 34, NUMBER 1 2013

telling him to follow a certain routine while Most medications have dosage-related side eating. Persons in stage four are likely only to effects, with higher dosages usually associated follow the notes if told that they failed to notice with higher risk. Adverse effects are more the notes spontaneously and are cued by the frequent in elderly patients and in particular caregiver. The person in stage five, however, those with renal or liver dysfunction. It is for will probably neither notice the notes nor this reason that initiation of medication should respond to them even when they are pointed start with a low dose and only be increased out. slowly. Adverse reactions associated with im- pairment in cognition increase with the number of medications taken. Decreases in cognitive ROLE OF THE SPEECH-LANGUAGE functioning may result from activity changes of PATHOLOGIST the neurotransmitters that depress central ner- Speech-language pathologists (SLPs) must be vous system (CNS) function, notably dopa- knowledgeable about medications and their mine, gamma-aminobutyric acid, serotonin, effect on cognition for several reasons. First, histamine, and .12 they must be aware of the patient’s response to medications because, as we have noted earlier, they can affect remediation, not only of cogni- PRINCIPLES OF tive, but of motor functioning as well. Second, PHARMACOTHERAPY it is important for SLPs to understand the Pharmacotherapy views medication from a optimal timing of medication response. For clinical standpoint and is defined as the use of example, a person with PD should ideally a particular medication to prevent, diagnose, receive treatment by an SLP at a time when and cure disease. The principles of anatomy and the dopamine in her body is at a peak level. physiology, , and pathophysiolo- Also, SLPs should be aware of when a variety gy are integrated in the study of pharmacother- of other therapeutic interventions may be apy. The study of pharmacokinetics as well as influencing the effectiveness of the medica- pharmacodynamics represents two subdivisions tions. Whirlpool sessions may result in a drop of pharmacotherapy. Pharmacokinetics looks at in pressure that, in turn, may increase how medications are absorbed, metabolized, the risk of orthostatic and poten- and eliminated by the body. Pharmacokinetics tial falls.7–9 Because medication-induced de- is essential in predicting medication drug levels lirium has numerous symptoms in common as well as predicting how long a medication will with dementia, medication as the cause for take before it reaches its desired level. Pharma- impairment of cognitive abilities should always codynamics describes the physiological effects be ruled out.1,7,8 Adverse drug reactions and of the medication on the body and describes the drug side effects need to be identified and medication’s mechanism of action at the cellular monitored by the clinician during the rehabil- level.13–15 Knowledge of pharmacotherapy as- itation process. For example, a combination of sists the clinician in better understanding of some and med- how a given patient’s medication is causing ications can result in increased extrapyramidal negative cognitive side effects. This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. symptoms. In addition, new symptoms may effects result from several medi- represent among several cations such as , , medications taken by the patient.10 Over half antidepressants, and benzodiazepines. Sedation a million persons are hospitalized per year is especially notable at the initiation of a in the United States due to adverse drug medication or immediately following a dosage reactions. Adding the negative events of non- change. Drowsiness usually occurs during the hospitalized individuals and the 125,000 first few weeks and then may disappear. The deaths that occur annually due to medication drowsiness can have a direct effect upon cogni- errors, it can be concluded that adverse drug tion. Sedation that continues to occur after this reactions constitute a major cause of death in time period is generally an indication that the America.11 dose needs to be changed or that the person is THE EFFECTS OF MEDICATION ON COGNITION IN LONG-TERM CARE/JOHNSON 21 suffering from a drug interaction. Drug inter- Older adults have a reduced ability to actions can occur in several different ways. For metabolize and excrete medications. Because example, the addition of a second drug may of changes in body composition as people age, interfere with the first drug’s effect. This is older people typically have higher levels of body known as an antagonistic effect. On the other fat than younger people. A decrease in lean body hand, the addition of the second drug may mass and total body water decreases both enhance the first drug’s effect. This is called and renal function. This results in potentiation.10 changes to the volume of distribution of med- ications that are water soluble. Increases in the medication in the bloodstream contribute to POLYPHARMACY increased effects and . Brain mass de- Polypharmacy is the condition of taking or creases, motor coordination decreases, reaction having been prescribed too many medications. time slows, and cerebral blood flow decreases, The United States is consuming prescription making short-term memory less efficient. The drugs at an alarming rate. Although the United blood–brain barrier is more permeable in the States represents less than 5% of the world’s elderly, allowing medications to cross into the population, it consumes nearly 75% of all CNS, and thereby increasing drug toxicity. manufactured pharmaceutical medications. Altered mental status is often related to the Americans spend an average of $8,200 per size of the dose, with higher risk seen in the year on medications—almost twice that of older person.10 other nations. The United States ranks 37th in overall health compared with many coun- tries, ranking below many in the Third CLASSES OF MEDICATIONS World.16 Drug interactions are more common AFFECTING COGNITION in the elderly. An analysis of the frail elderly found that the patients took an average of 15 Benzodiazepines medications (range 6 to 28), with 8.9 drug- Benzodiazepines are antianxiety medications related problems per patient (range 3 to 19).17 It such as Xanax, Ativan, Librium, and Valium. was noted that in many instances, patients were Benzodiazepines have , hypnot- often taking medications that were no longer ic, muscle relaxant, and sedative effects. Used needed for their medical problems and that judiciously, these medications can enhance the these medications were contributing to side person’s psychological and physical well-being. effects. Typical medications no longer required Altered drug disposition, however, results in have included antihypertensive medications, the elderly being sensitive to the drug’s side proton pump inhibitors, and iron. effects. This can lead to psychological and Drug-related morbidity in the frail elderly physical decline with the addition of other can be avoided. Much of the difficulty lies in medications and the risk of drug interaction.19 inappropriate prescribing.18 The elderly experi- These medications can result in sedation, con- ence more age-related changes to the body than fusion, and falls. They also can result in antero- younger persons do. The elderly may experience grade amnesia. Benzodiazepines also shorten This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. confusion due to polypharmacy combined with sleep onset and suppress stage four and REM visual difficulties, auditory difficulties, and mem- sleep (suppressing dreams). When benzodiaze- ory impairments. The elderly may also not pine therapy is initiated, it is suggested that understand the drug treatment plan, and as a short-acting medications be utilized. For ex- result fail to comply. In addition, the elderly ample, Xanax has a shorter half-life and is historically have a higher level of polypharmacy preferred over the long half-life benzodiaze- due to multiple health problems. Many elderly pines. Long-acting benzodiazepines (such as persons live alone, have difficulty affording their Valium) can result in profound cognitive im- prescriptions, or have difficulty visiting their pairment, profound confusion, forgetfulness, physician. These challenges can result in medi- morning hangover effect, and falls.10,19 All cation side effects and thus cognitive problems.18 benzodiazepines work to decrease . 22 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 34, NUMBER 1 2013

The choice of which to use interactions with antianxiety and sleep agents depends on rate of onset, rate of elimination, present a mixed drug picture based on the potential side effects, and drug interactions. For . For example, drug interaction example, SLPs need to check medications when between Xanax and Prozac can result in in- working with an elderly person who has dys- creased sedation. Interaction with Valium and phagia. This patient may complain of a lack of Luvox can also increase sedation. Drug inter- appetite due to a loss of taste. Benzodiazepines actions between BuSpar and Prozac, however, such as Xanax, however, will result in taste loss result in a decreased effect of Prozac.12,20,21 and lessening interest in food and eating. Drug interactions with medications such as , chronic obstructive pulmonary disease Antipsychotic Agents medications, anti-infective medications, anti- Antipsychotic agents such as Haldol, Mellaril, , and cardiac medication generally and Thorazine (first-generation) used in the result in decreased benzodiazepine clearance treatment of delusions and can and increased sedation that affects cognition. result in confusion, sedation, Parkinsonism, For example, Valium mixed with , Pri- and tardive dyskinesia. The sedation effect, losec, or Prozac and Xanax mixed with Tagamet however, is mixed, and depends on the particu- will result in decreased benzodiazepine clear- lar medication. For example, Thorazine, Seren- ance and increased sedation.12 til, and Mellaril have a high probability of sedation and a low to moderate probability of extrapyramidal symptoms. Haldol and Orap, on Antidepressants the other hand, have a low probability of Depression is a psychiatric illness with symp- sedation and a high probability of extrapyrami- toms that reflect loss of ability to concentrate or dal symptoms.22,23 Atypical antipsychotics experience pleasure. This disorder also includes (second-generation) also present a mixed pic- apathy, social withdrawal, guilt, and sleep and ture of sedation. Dibenzapines (Clozaril, Zy- appetite disturbances. The commonly seen side prexa, and Seroquel) demonstrate a high effects of these medications include changes in probability for sedation. Benzisoxazoles (Ris- heart rate and rhythm, hypotension, and hy- perdal) present a low probability of sedation, pertension and sedation. The side effect of whereas Geodon presents a moderate probabil- sedation associated with antidepressants can ity of sedation. Aripiprazole (Abilify) presents a result in decreased attention to eating and low probability of sedation. Antipsychotic drug decreased appetite, especially with therapy ini- interactions with medications that are anticho- tiation or with dosage change. The feeling of linergic (antihistamines, tricyclic antidepres- drowsiness usually occurs during the first sants, anti-Parkinson’s agents) will result in 2 weeks upon medication initiation and then decreased antipsychotic effects. Drug interac- generally diminishes. Sedation that remains tions with benzodiazepines (Valium, Librium) after the first several weeks is an indication to will result in respiratory depression, ataxia, consider drug interactions or lowering of dos- stupor, and additive sedation.10,12 age.20,21 The tricyclic and tetracycline antide- This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. pressants such as Elavil generally present a high probability of sedation. Selective serotonin re- Antihistamines uptake inhibitors such as Prozac, Paxil, Zoloft, Histamine contributes to a local response of and Effexor present with a low probability of inflammation. Subsequently, antihistamines re- sedation. Atypical antidepressants present a duce inflammation. Antihistamines (such as mixed picture regarding sedation. For example, ) are used to treat and sinus Wellbutrin presents a low probability of seda- problems. Antihistamines can result in sedation tion whereas Remeron and Serzone present a and confusion and sleep disturbances. Antihist- high probability of sedation.21 amines are one of many medi- Antidepressants can result in CNS effects cations that often cause .12 The such as agitation, confusion, and sedation. Drug antihistamine Benadryl syrup (12.5 mg/5 mil THE EFFECTS OF MEDICATION ON COGNITION IN LONG-TERM CARE/JOHNSON 23 concentration) may be used as a topical with age of 65, at least 20% are taking an anticho- products such as Magic Mouthwash for stoma- linergic medication. For example, common titis (inflammation of the mucosal lining of the medications such as the heart drug digoxin, mouth). The side effect, however (if swal- the blood thinner warfarin, the painkiller co- lowed), is decreased gastrointestinal mobility, deine, and the steroid prednisone are all con- , xerostomia, and sedation.24 sidered mild anticholinergics. Patients who are taking three or more anticholinergic medica- tions for more than 90 days are over three times more likely to develop mild cognitive im- Antiemetics used for relief such as pairment. Those with the most severe side Pherergan will also result in confusion, seda- effects include Paxil, Benadryl, a drug for tion, Parkinsonism, and tardive dyskinesia. overactive bladder called oxybutynin, and the schizophrenia drug clozapine. The clinician should keep in mind that there are many over-the-counter drugs including med- Analgesics used in relief such as Darvon ications and Tylenol PM whose anticholinergic can also result in confusion and sedation.18 effects can significantly reduce cognitive function.26

Prolonged Use of Medications Regular use of psychiatric drugs, antihist- Lipid-Soluble Medications amines, and pain medications can result in Lipid-soluble medications may also contribute cognitive decline and memory loss. For exam- to reduced cognition. Lipid-soluble agents stay ple, anticholinergics function to block the neu- in the fatty tissues of the body and slowly enter rotransmitter acetylcholine. Acetylcholine is the bloodstream, resulting in longer periods of one of the main neurotransmitters responsible sedation. This combined with the depth of the for memory and cognition. The difficulty with and the length of time under anes- anticholinergic medications is that they are thesia accounts for what some patients may call cumulative. The physician may not be aware the “hangover effect” associated with anesthe- of all of the anticholinergic medications in the sia. This hangover effect results in cognitive patient’s drug regimen. People taking at least impairment such as word-finding difficulties one anticholinergic medication scored lower on and short-term memory loss following . cognitive functioning measures than those sub- Subsequently, anesthesiologists monitor the jects not receiving anticholinergic medication. length and depth of the anesthesia to avoid In addition, there was a death rate for heavy these complications.7,9,12 users of 68%.25 The researchers assumed that the anticholinergics were causing significant stress on body organs and systems. The anti- Cholesterol-Lowering Drugs cholinergics were also identified as influencing Cholesterol-lowering drugs such as Crestor and delirium. American studies have substantiated Lipitor have been credited with saving the lives This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. the above. Americans who took an average of of many patients with cardiac disease. However, three to four anticholinergic medications in a a small number of recent studies have linked 90-day period were three times more likely to cholesterol-lowering drugs to learning difficul- develop cognitive disorders than those patients ties and memory loss.27 There is concern that not taking anticholinergic medications.25 An- the person’s learning difficulties and memory ticholinergic medications need to be prescribed loss could be misdiagnosed as dementia. Other for the elderly with caution. Not only are studies have failed to find this link. Current doctors often unaware of all the medicines their thought is that there may be a small percentage patients are taking, but the list of drugs with of patients susceptible to cholesterol-lowering anticholinergic properties is a long one. For drugs. In the susceptible group, it may be just a instance, of the 36 million Americans over the matter of changing .27 24 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 34, NUMBER 1 2013

CNS Medications agents such as piracetam, oxir- Medications such as benzodiazepines, antipsy- acetam, and aniracetam are known as cognitive chotic medications, , and other relat- enhancers. These cognitive enhancers work by ed pain medications as well as antidepressants increasing brain blood flow, brain metabolism, including selective serotonin reuptake inhibi- and oxygen supply to the brain as well as tors are identified as CNS medications. These neurotransmitter production in the brain. medications all affect the and These agents have been used for several cogni- the brain. Although these medications are tive disorders such as postconcussion syndrome, useful for the treatment of health difficulties dyslexia, and dementia. The efficacy of these such as anxiety, depression, and pain, they can agents is still open to question.1 have a definite negative effect upon cognition. Naftidrofuryl (Praxilene) is an agent In one study, 25% of the patients demon- thought to stimulate cerebral blood flow. Effi- strated cognitive decline,27 most notably in cacy studies have shown a mixed result with this memory and executive function. Those pa- agent for improving cognitive function.1 tients receiving higher dosages of the medi- The inhibitors are the cations over a longer period of time showed most frequently used medications for disorders the most declines. Changing the medication such as AD to increase cognitive functioning. to another drug in the same category of CNS The physiological activity of acetylcholine has drugs may result in a positive change in been known since the early 19th century. The cognition.18 Obviously, SLPs cannot change neurotransmitter role of acetylcholine has been medications. However, the prudent SLP known since the mid-1920s. It is known that needs to become “best friends” with the cholinergic degeneration occurs early in AD agency pharmacist. Every level of health and that degeneration is associated with cogni- care, from hospital to home care, has a con- tive function decline. Several medications have sulting pharmacist who can work with the been subsequently developed to inhibit the loss therapist and make recommendations to the of acetylcholine.1,12 physician.28 Tacrine (Cognex) was the first agent developed as an acetylcholine inhibitor for AD. Trials of the agent resulted in an approx- Medications That May Increase imate 50% dropout rate secondary to adverse Cognitive Ability side effects. These side effects occurred in Although many medications are described as 94% of patients. They included , decreasing cognitive abilities, there are sev- diarrhea, , ataxia, flushing, sweating, eral that are purported to increase cognitive tremor, and orthostatic hypotension. Many of skills. These medications are thought to the side effects resulted in a decrease in oral alleviate some of the symptoms of cognitive intake and dysphagia. This acetylcholine in- loss in disorders such as AD. These medi- hibitor agent also reported elevated liver cations, however, do not change the under- enzymes in over 50% of the cases. This lying cause. elevation in enzymes returned to normal One medication that has been available with discontinuation of the medication. This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. since the early 1950s is codergocrine (Hyder- This agent has a short half-life of 2 to 3 gine). This medication is not used extensively at hours, thus requiring dosage several times this time. There is agreement, however, that daily, and was effective in improving cogni- this drug can improve self-care and activities of tion and “setting the time back” to daily living. This medication does not have any 12 months.1,12 Another acetylcholine inhibi- specific antidementia effect. It has the effect of tor agent is Aricept. This medication received elevating mood. It is used as an adjunct to positive efficacy reports for patients described clinical management of mild to moderate cases with mild to moderate dementia.1,12 of AD in the United Kingdom. It is used as part Dropout rates range from 7 to 32%. Nega- of the clinical treatment of idiopathic mental tive adverse effects were generally mild and decline in the United States.1 related to vomiting, nausea, diarrhea, , THE EFFECTS OF MEDICATION ON COGNITION IN LONG-TERM CARE/JOHNSON 25 and anorexia. Side effects were diminished by other hand, recent studies have begun to ques- starting the medication at a lower dose and tion the efficacy of this medication. Side effects titrating over a 6-week period. Aricept has a include fatigue, hypertension, agitation, drows- long half-life of 70 to 80 hours, which allows for iness, confusion, constipation, diarrhea, and daily dosing. Some patients become “emotion- urinary incontinence. None of the preciously ally negative” on Aricept, but discontinuation of listed medications for cognitive enhancement the medication corrects the problem. Aricept will achieve total repair of cognitive functioning comes in dosages of 5, 10, 15, 20, and 23 mg. in the patient. Some studies have pointed to an The 23-mg dose was introduced just recently overall improvement of 10 to 15% in the and was designed for more severely involved patient.1 patients. Following the mantra “start low and Whether it is medications that result in an go slow,” the patient is best started at the 5-mg increase in cognition or medications that de- dose and titrated slowly. Overall it appears that crease cognition, there are several guidelines over 40% of patients with Alzheimer’s benefit that are helpful for the clinician as well as the from this agent cognitively.1,12 patient taking the medicine. A third acetylcholine inhibitor agent is Exelon, which is also available in patch form. Always ask the doctor to begin with the This agent is usually dosed twice daily. It is lowest dose and slowly increase the dose in not metabolized by the liver. Drug interac- coordination with the physician’s recom- tions are very low. This medication was mendation. This is particularly true initially developed for people with PD, but for elderly patients with multiple it has been utilized with Aricept in some medications. patients where improvement in memory was Avoid the use of multiple antipsychotic med- paramount.1,12 ications and anticholinergic medications. The last acetylcholine inhibitor agent is Avoid medications with side effects that galantamine (Reminyl). Some studies have in- exacerbate the patient’s clinical conditions. dicated improvements for 9 months. This Avoid taking over-the-counter medications agent was renamed Razadyne due to the famil- without checking with the physician. iarity of the original name to another drug. In Ensure that the patient has a regular bowel the same year, the Food and Drug Administra- program when taking anticholinergic med- tion issued a black box warning for this medi- ications, pain medications, and psychotropic cation. A black box warning is issued to warn medications. the prescriber that use of this medication has Bedside medications should be taken at least been associated with serious side effects and 10 minutes before reclining and in an up- life-threatening risks. Galantamine is not used right position. as frequently as Aricept and Exelon. Medications should be taken with adequate Memantine (Namenda) was also intro- amounts of water. duced as a cognitive enhancer. This medication Medications at risk for esophageal lodging acts differently from the acetylcholine inhib- should be taken early in the day and not at itors discussed previously. It has a long half-life bedtime. This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. of 60 to 80 hours. This drug comes in dosages of Patients with a history of gastroesopha- 5, 10, 15, and 20 mg. Similar to Aricept, the geal reflux disease should be instructed manufacturer states that this medication can be about the foods that may exacerbate the taken by itself, but “does better” in combination condition. with another medication. For this reason, Ari- The clinician needs to be aware of any cept and Namenda are frequently used together. changes in cognition with changes in the Titration can occur every 7 days until a daily patient’s medication regimen. These dose of 20 mg is obtained. Dosages should be changes need to be reported to the physician. lower for patients with renal disease. There have The clinician needs to develop a working been numerous studies pointing to the positive relationship with both the physician and cognitive effects of this medication. On the pharmacist. 26 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 34, NUMBER 1 2013

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